GI Problems in Athletes

1
GI Problems in Athletes

• William Dexter, MD, FACSM
• Maine Medical Center
• Sports Medicine

2
My thanks to.

• Mark Snowise, MD
• Suburban Medical
• Pittsfield, MA

• Mike Pleacher, MD
• Intermountain Healthcare, Ogden UT

3
Overview

• Upper GI
• Runners Diarhea
• Epidemiology
• Etiology
• Common issues
• Evaluation
• Treatment

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Evidence Base . . .

• Lacking . . .
• majority of published work has studied normal
  subjects under submaximal efforts for relatively
  short durations.
• incidence of exercise-associated GI bleeding is
  uncertain and studies are inconclusive.
• Ex use FOBT non specific

Moses, CSMR 2005, 49195
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GI Problems Common

• Upper
• heartburn, chest pain, belching, epigastric pain,
  nausea, and vomiting
• reported by up to 50 of athletes during heavy
  exercise

Casey, ClinSportMed 2005 24525-40 Peters,
CSMR2004, 3107111
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GI Problems Common

• Lower
• Ex runners trots

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GI Problems Common

• Prevalence of GI symptoms
• Higher during running
• Women gt men
• More common in younger athletes
• Less frequent in low impact sports
• Exercise intensity
• Marathoners 30-80 report GI Sx
• GI Bleeding can be seen (8 - 85)
• All sports report
• 8 to 22 of marathon runners report gross fecal
  blood loss

Jaworski, CSMR 2005, 4137143 Casey,
ClinSportMed 2005 24525-40 Peters, CSMR 2004,
3107111
8
GI Problems Common

• Mechanical
• Dietary
• Ingestions meds, etc
• Poor adaptation
• Emotional
• Infection VGE, travel, other
• Inflammatory UC, Crohns
• Functional

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Benign to catastrophic

• May interfere with athletic activities
• (requiring significant accommodations)

• May also be associated with significant disease

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Benign to catastrophic

• May mimic or be an harbinger of other more
  ominous pathology
• GERD CVD
• Multiple etiologies
• Heme pos stool
• Abdominal pain and bleeding
• Be attentive, be thorough

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Suffering in Silence

• Poorly understood
• By athletes
• By sports med staff
• Symptoms often ignored
• Commonly
• Self diagnosed
• Self treated

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Gastrointestinal Issues in Athletes Upper Gut
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General

• Regular moderate physical activity has been
  associated with
• Enhanced gastric emptying
• Improved GI motility
• Lower risk for liver disease, cholelithiasis,
  diverticulosis, colon CA
• Less constipation

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Etiology

• Delayed gastric emptying
• Transit time
• LES changes
• Gastric distension
• Gastric blood flow
• Increased vibration
• Increased levels of hormones
• Fluid intake
• Psychologic

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Mechanism

• Slowed motility
• Duration, amplitude and frequency of esophageal
  contractions
• Decline with exercise intensity over 90 VO2max
• Lowered LES pressure
• Increased reflux episodes
• Documented in cyclists gt 70 VO2max

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Delayed gastric emptying

• Dehydration can slow GE up to 40
• Hypertonic carbohydrate beverages can also slow
  GE
• Sig delay in gastric emptying above 70 VO2max
• Delayed gastric emptying can lower LES tone

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GI blood flow

• Reduced in excess of 50
• Estimated hepatic blood flow (EHBF)
• 12-14 decrease at 30-35 VO2max
• 30-45 decrease with 35-60 VO2max
• Portal vein blood flow in cyclists
• 20 min at 70 VO2max SBF decreased by 57
• After 1 hr SBF decreased by 80
• Predisposes to gut injury
• Increases membrane permeability
• Enhances occult blood loss
• Generated endotoxins that can increase diarrhea

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Fluid intake

• Gastric emptying is slowed with heavy exercise in
  dehydrated state
• Exercise releases catecholamines that suppress
  thirst
• Some athletes cannot tolerate sensation of
  food/fluid in the stomach with exercise
• 80 of marathon finishers with gt 4 weight loss
  due to dehydration experienced GI symptoms

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Psychologic

• Stress can exacerbate GI symptoms
• Up to 57 of athletes with runners diarrhea
  complained of symptoms prior to race, 32 had
  similar symptoms when emotionally stressed

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Upper GI Symptoms

• Dysphagia
• Oropharyngeal dysphagia
• Esophageal dysphagia
• GERD
• Dyspepsia
• GI bleeding

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Dysphagia

• Oropharyngeal dysphagia (OD)
• Liquids (v solids)
• Choking sensation, incomplete swallowing
• Occurs within a few seconds of swallowing
• Pain localizes to neck
• Can also see a change in dietary habits,
  dehydration, regurgitation, weight loss

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Dysphagia
Oropharyngeal dysphagia

• Common causes
• Tonsillitis
• Pharyngitis
• Laryngitis
• Cervical adenitis
• Thyromegaly

• Less common causes
• Ludwigs angina
• Retropharyngeal abscess
• Anaphylaxis

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Dysphagia

• Esophageal dysphagia
• Solids and liquids
• More delayed than OD
• Pain localized to 6th thoracic dermatome
• Poorly defined substernal pressure, burning,
  chest pain

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Dysphagia

• GERD MC cause
• Less common causes include
• Infectious HSV, Candida, CMV
• Caustic injury
• Pill esophagitis
• Aortic aneurysm
• Mechanical obstruction
• Motility disorders

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GERD

• 60 of athletes
• More frequent with exercise
• Ambulatory pH probe monitoring has shown that
  exercise exacerbates reflux
• Sport specific
• Anaerobic sports report most symptoms
• Runners gt cyclists

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GERD

• Classic heart burn symptoms
• Worse with exertion, laying flat at night,
• Worse after a big meal, fried fatty foods
• Chest pain
• Nausea, vomiting, abdominal pain
• Silent GERD
• Night time coughing, wheezing

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Dyspepsia

• Varied complaints including nausea,
  gnawing/burning epigastric pain, vomiting,
  eructation, bloating, indigestion, generalized
  abdominal discomfort
• MC causes include
• PUD
• GERD
• Gastritis

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Dyspepsia

• Common cause is mucosal damage
• Frequent dehydration
• Repeated stress of racing
• Excessive NSAID use
• Medications
• ETOH
• Caffeine
• Dietary supplements containing AA and creatine

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GI bleeding

• Can be upper or lower
• Usually transient
• Well documented in distance runners
• Endoscopy study
• N16 runners
• All had some degree of gastritis,
• 4 with heme positive stool
• 2 with lower GI source

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GI Bleeding

• Mechanism includes
• Hemorrhagic colitis
• NSAID induced gastritis
• Traumatic hemolysis
• Impaired gut absorption
• Mechanical trauma lower incidence in cyclists
  than runners

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Evaluation

• History diagnosis in about 80 of cases
• Onset
• Exacerbating factors
• Pain
• Gross blood
• PMHx
• FHx
• SHx TOB, ETOH, other drugs
• Dietary history chocolate, caffeine, timing
• Psychosocial history ? stress
• NSAIDs

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Exam

• General Fever, orthostatic
• HEENT
• Looking for any physical signs of obstruction
• Palpate thyroid
• CV
• Lung
• GI tenderness, mass
• Stool occult blood cards

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Evaluation

• Throat Cx
• Labs GI bleed
• CBC, CCP, TSH, Ferritin, Iron Panel
• Other labs H pylori, Celiac sprue
• UGI ?
• EGD if hemoptysis, melena, resistant or
  prolonged Sxs
• Colonoscopy if gross blood

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Evaluation

• Alarm Symptoms
• Weight loss
• Progressive dysphagia
• Recurrent vomiting
• GI bleeding
• Family history of CA

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Treatment

• Treat underlying infection
• Dyspepsia treat H pylori if positive (AGA
  guidelines)
• Diet modification
• Avoid ETOH, TOB, fatty foods, mints, chocolate,
  caffeine, citrus
• Timing of pre-exercise meals
• Elevate head of bed
• No food w/in 4 hours of going to bed

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Treatment

• Literature for PPI vs H2 blockers is limited in
  athletes
• PPI are more effective than H2 blockers in
  treating PUD and GERD (Up to Date)
• No difference between PPIs
• Usual trial of H2 blocker or PPI
• Intermittent Sx H2 blocker
• Daily Sxs PPI
• H2 blockers show varied success in decreasing
  blood loss
• PPI may decrease GIB

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Treatment

• Maintain hydration
• Avoid NSAIDs
• Consider iron supplementation
• Optimize fiber

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Upper GI Summary

• Upper GI symptoms are very common
• Runners mostly affected
• History will give diagnosis in majority of cases
• Empiric therapy with H2 blocker or PPI
• Immediate evaluation with gross blood or abnormal
  exam findings

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Common Medical ConditionsRunners Diarrhea
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Exercise and the GI Tract

• Association between exercise and changes in the
  GI tract has long been appreciated
• 1794, Dr. John Puch wrote in Treatise on the
  Science of Muscular Action that
• Exercise helps to throw down wind from the
  bowels and attenuates the contents of the
  stomach. It also serves at once as an evacuant

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Exercise and the GI Tract

• Common Lower GI Symptoms
• Flatulence
• Diarrhea
• Hematochezia
• Urgency to defecate

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Defining Runners Diarrhea

• Runners Trots first coined in 1980 to
  describe episodes of bloody diarrhea in 2
  marathon runners
• Case definition
• non-bloody or bloody diarrhea
• lower abdominal cramping
• frequency and urgency
• occurs during endurance events

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Epidemiology of Runners Diarrhea

• Most commonly affects runners
• Estimates of incidence 20 - 33
• 50 endurance athletes report fecal urgency
  following training runs
• 20 of marathoners have occult blood in stool
  after races,
• 17 reported frank hematochezia during training
  for marathons
• Affects more females than males

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Etiology of Runners Diarrhea

• Complete understanding of the etiology of
  runners diarrhea remains unclear
• Altered intestinal transit time
• Altered GI blood flow
• Fluid/electrolyte shifts at cellular level
• Mechanical causes

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Etiology of Runners Diarrhea

• Complete understanding of the etiology of
  runners diarrhea remains unclear
• Autonomic nervous system stimulation
• Changes in GI hormones
• Diet and medications

Bob S. training for marathon, exhibiting a. ANS
stimulation b. Signs of change in his GI
hormones c. Medication effects
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Altered GI Transit Time

• Decreased colonic transit time?
• Cordain et al found that transit time decreased
  from 35 to 24 hours in sedentary individuals who
  started exercise program
• Others have found that oro-cecal transit time is
  actually increased in strenuous exercise but
  decreased in light exercise

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Altered GI Blood Flow

• Intense exercise reduces blood flow to the GI
  tract by 80
• Reduction in colonic blood flow more marked when
  dehydration is present
• 80 of athletes who are greater than 4
  dehydrated develop lower GI symptoms

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Diet and Medications

• Lactose intolerance
• High fiber diet
• Artificial sweeteners
• Sorbitol and aspartame
• Commonly used in sports drinks
• May lead to osmotic diarrhea
• Meds antibiotics, H2 Blockers, Mg-containing
  antacids
• Laxatives

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Other Etiologic Factors

• Mechanical compression of colon by
  hypertrophied psoas muscle
• GI Hormone Changes elevation in gastrin,
  motilin, and VIP has been demonstrated during
  exercise
• Autonomic Nervous System increased
  parasympathetic tone during exercise leads to
  increased transit time due to smooth muscle
  contraction

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Differential Diagnosis for a Runner with Diarrhea

• Runners Diarrhea is a diagnosis of exclusion
• lt 40 years of age
• infectious,
• inflammatory
• dietary problems
• gt 40 years of age
• As above AND
• consider malignancy
• diverticular disease
• Evaluation is based on age-stratification

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Evaluation of Runner with Diarrhea

• All Patients careful history
• Timing, characteristics of diarrhea
• Diet and hydration history
• Travel history
• ROS fever, wt loss,
• abd pain, jaundice
• PMH, FHx
• Medications

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Evaluation Physical Exam

• Careful physical examination for all pts
• Vitals (temperature and weight)
• Abdominal exam tenderness, masses, bowel sounds,
  hepatomegaly
• Rectal exam
• sphincter tone,
• occult blood

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Evaluation Ancillary Studies

• In young (lt40 yo) athletes
• Stool studies occult blood, culture, OP
• Consider fecal fat if malabsorption possible
• CBC anemia, leukocytosis
• Metabolic Profile hypokalemia
• ESR/CRP
• Consider Hydrogen breath test
• Consider Flexible Sigmoidoscopy
• Consider HIV testing

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Evaluation Ancillary Studies

• Older athletes (gt40 yo)
• Same studies as for younger athletes, except
• Comprehensive metabolic profile
• Complete Colonoscopy rather than Flex Sig to
  evaluate for cancer or diverticulae

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Treatment

• Treat any underlying condition
• If no underlying condition is found during
  evaluation, consider multi-modal approach to
  treatment
• Dietary changes
• Medications
• Training changes and environmental changes

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Treatment

• Dietary Changes
• Avoid sugar alcohols (sorbitol)
• Low-residue, low-fiber diet
• Consider restricting lactose
• Reduce caffeine intake
• Improve hydration

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Treatment

• Pharmacologic approach
• Only one study published on pharmacologic
  treatment
• Lopez compared diosmectate (Al silicate) with
  loperamide diarrhea resolved in 72 vs. 20
• Anticholinergics (atropine) and opiates
  (loperamide) have been used
• Most US experts recommend
• OTC loperamide 30 minutes prior to exercise

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Treatment

• Training and Environmental Changes
• Reduction of intensity and duration of training
  runs often relieves symptoms
• Consider cross-training
• Timing of training runs to reduce likelihood of
  dehydration
• Daily ritual of pre-exercise bowel evacuation is
  mandatory

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Summary

• Runners Diarrhea is quite common
• Multi-factorial etiology
• Diagnosis of exclusion
• Very little evidence for treatment approaches
• Success rate of treatments unknown
• Given high incidence of this problem, future
  study seems warranted